A North America “Free Toes” Alliance (NAFTA)? Teaming up to #ActAgainstAmputation worldwide #DiabeticFoot @VascularSVS @APMA

This work from our friends from Mexico City, Toronto and our team, stems from a lecture series that Joe Mills and I created several years ago entitled “The North American Free Toes Alliance” featuring Mexican Vascular Surgeon Dra. Rocio Jimenez. This was revisited by Dr. Carlos Hinojosa in “Renegotiating NAFTA”. It was Carlos’ leadership that created this manuscript. Enjoy!

The importance of establishing a framework
for regional and international collaboration in
the management of the diabetic foot

The global prevalence of diabetes mellitus continues to rise; estimates are that it will affect 350 million people (4.4% of the global population) by the year 2030.1 Associated complications of diabetes are likewise increasing.2 Diabetic foot ulceration (DFU) is complex and costly, being the most frequent cause of hospitalization in this population of patients.2,3 In Mexico, there are approximately 12 million people with diabetes mellitus, and the health care cost is 2.3% of the gross domestic product, mostly to treat complications associated with DFU.3 Last year, the Department of Surgery of the National Institute of Medical Sciences and Nutrition Salvador Zubirán in Mexico City held a multi- disciplinary congress with 44 participating panelists who analyzed 126 proposals for DFU management. The conclusions and recommendations derived from this meeting emphasized the need for updated classification systems 4 and clinical practice guidelines,2 the publication of a position document in Mexico, and the development of courses by qualified and certified groups supported by the National Academy of Medicine for the preparation and training of health care providers in this area.5,6
Communication in health care has always been and still remains a key element in the exchange of scientific knowledge; clinical experience; and modification or reinforcement of behaviors, values, and social norms that ultimately contribute to positive self-care practices,

quality of life, and better patient-physician relationships. In October 2018, the Diabetic Foot International Conference (DFCon) was held in Houston, Texas, during which a world-renowned faculty composed of multiple clinical disciplines, innovators, and researchers from Europe, Asia, Oceania, Africa, and the Americas discussed important topics in this area.7 This led a notable forum to propose a North American Free Toes Alliance (NAFTA), an acronym used for 24 years in the Trade Agreement between the United States, Canada, and Mexico. The North American Free Trade Agreement (NAFTA) has bound the economies together since 1994, removing import and export barriers. The proposed “North American Free Toes Alliance” would strive to develop and to integrate a regional, trinational regis- try to evaluate clinical outcomes in the management of DFU. This international initiative could simultaneously serve as an important platform for patients seeking centers of excellence for DFU care. We are convinced that the evaluation of our initial results by a third, independent organization such as the International Working Group on the Diabetic Foot would be crucial and an important pathway toward the possible adaptation and implementation of such multinational efforts in other regions of the world.8
The optimization of communication and the design of effective platforms will allow the generation of new and available and, more important, public medical information, research protocols, and practice guidelines. The creation of an international standard of medical care and opportunities for academic exchange of information would be the primary objectives of this effort. This effort could serve as a model for other regions across the globe.

Carlos A. Hinojosa, MD, MSc
Javier E. Anaya-Ayala, MD, MSc

Section of Vascular Surgery and Endovascular Therapy
Department of Surgery
Instituto Nacional de Ciencias Médicas y Nutrición Salvador
Universidad Nacional Autonoma de Mexico
Mexico City, Mexico

David G. Armstrong, DPM, MD, PhD
Department of Surgery
University of Southern California
Los Angeles, Calif

Ahmed Kayssi, MD, MSc, MPH
Division of Vascular Surgery
Department of Surgery
Sunnybrook Research Institute
Sunnybrook Health Sciences Center
University of Toronto
Toronto, Ontario, Canada

Joseph L. Mills Sr, MD
Division of Vascular Surgery and Endovascular Therapy
Michel E. DeBakey Department of Surgery
Baylor College of Medicine
Houston, Tex

  1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
  2. Hingorani A, LaMuraglia GM, Henke P, Meissner MH, Loretz L, Zinszer KM, et al. The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Associa- tion and the Society for Vascular Medicine. J Vasc Surg 2016;63(Suppl):3S-21S.
  3. Hinojosa CA, Boyer-Duck E, Anaya-Ayala JE, Nunez-Salgado A, Laparra-Escareno H, Torres-Machorro A, et al. Impact of the bacteriology of diabetic foot ulcers in limb loss. Wound Repair Regen 2016;24:923-7.
  4. Mills JL, Conte MS, Armstrong DG, Pomposelli F, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk strati- fi
    cation based on Wound, Ischemia and foot Infection (WIfI). J Vasc Surg 2014;59:220-34.
  5. Cisneros-González N, Ascencio-Montiel IJ, Libreros-Bango VN, Rodríguez-Vázquez H, Campos-Hernández Á, Dávila-Torres J, et al. Lower extremity amputation rates in diabetic patients. Rev Med Inst Mex Seguro Soc 2016;54:472-9.
  6. Annual vascular surgery meeting. Dr Hector Orozco. Available at: http://bit.ly/dfootMx. Accessed January 31, 2019.
  7. 18th Diabetic Foot Global Conference. Available at: http:// dfcon.com/. Accessed January 31, 2019.
  8. International Working Group on the Diabetic Foot. Available at: http://www.d-foot.org/d-foot/. Accessed January 31, 2019.

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